Anda di halaman 1dari 3

Nama : Diyah Purwanti

STIKes Hafshawaty NIM : 14901.04.17011


Zainul Hasan Genggong Probolinggo

RESUME KEPERAWATAN
Pada Ny H Dengan Kasus Spondilolitiasis
(Format Pengkajian Poli Ortophedi)

Data diambil tanggal : Jam………


No. Rekam Medik :

I. IDENTITAS KLIEN
Nama :
Umur :
Jenis Kelamin :
Suku / Bangsa :
Agama Pekerjaan :
Pendidikan :
Alamat :
No. Register :
Tanggal MRS :
Diagnosa Medis :
Sumber Informasi :
Penanggung : Askes / Astek / Jamsostek / JPS / Sendiri

II. KELUHAN UTAMA


……………………………………………………………………………………………………………….................
……………..
………………………………………………………………………………………………………………………................
..…….
………………………………………………………………………………………………………………………................
..…….

III. KRONOLOGIS PENYAKIT SEKARANG


...............................................................................................................................................................
...............................................................................................................................................................
............................................................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................

1
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................
...............................................................................................................................................................
..............................

IV. PEMERIKSAAN FISIK YANG BERHUBUNGAN DENGAN KASUS


1. Status Kesehatan Umum
Keadaan Penyakit :
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................
...........................................................................................................................................................
.............................
2. Sikap / postur tubuh
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................
3. Mobilitas tulang belakang
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................
V. PEMERIKSAAN DIAGNOSTIK DAN PENATALAKSANAAN
.......................................................................................................................................................
.......................................................................................................................................................

2
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

VI. ANALISA DATA


a. Data Subyektif :
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................

b. Data Obyektif :
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................

VII. DIAGNOSA KEPERAWATAN


1. .........................................................................................................................................................
...........................
2. .........................................................................................................................................................
...........................
3. .........................................................................................................................................................
...........................

Surabaya, ..............................2018
Mahasiswa,

DIYAH PURWANTI